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ACE inhibitors and Angiotensin-II antagonists should not be used by breast feeding mothers in the first few weeks after delivery because of profound neonatal hypotension; pre-term babies may be at particular risk. For more details see Drug Safety Update, May 2009.

Combining medicines from different classes of renin-angiotensin system blocking agents increases the risk of hyperkalaemia, hypotension and impaired renal function. Combination use of medicines from two classes of RAS blocking agents (ACE-inhibitors, ARBs or aliskiren) is not recommended. In particular, prescribers are advised that people with diabetic nephropathy should not be given an ACE-inhibitor with an angiotensin-receptor blocker as they are already prone to developing hyperkalaemia. For more details, seeDrug Safety Update, June 2014.

When co-prescribing an angiotensin converting enzyme inhibitor or an angiotensin receptor blocker with spironolactone or other potassium sparing diuretics, monitoring of blood electrolytes is essential due to the risk of hyperkalaemia. For more information, see Drug Safety Update, February 2016.

Prescribing notes

Angiotensin-converting enzyme (ACE) inhibitors

ACE inhibitors may be considered first-line antihypertensives in diabetic patients and for newly diagnosed patients less than 55 years old.

ACE inhibitors have been shown to relieve symptoms and improve survival in all classes of heart failure.

Doses should be titrated to the maximum tolerated dose, especially in patients with heart failure.

Side effects: can cause a persistant dry cough, which may benefit from inhaled sodium cromoglicate, 2 puffs four times a day.

For those who develop a persistent cough with ACE inhibitors, an angiotensin-II receptor antagonist may be considered as an alternative.

Renal failure: ACE inhibitors are partially excreted by the kidneys, so accumulation occurs in renal impairment. Renal function and electrolytes should be checked before starting ACE inhibitors and monitored during treatment more frequently in renal disease. Concomitant use with NSAIDs increases the risk of renal damage, (especially in the peri-operative period).

Angiotensin-II receptor antagonists are second-line antihypertensives; they may be an alternative for pateints for whom ACE inhibitors are clinically indicated but who found ACE inhibitor cough unacceptable.

Irbesartan and losartan are licensed for treatment of diabetic nephropathy in type 2 diabetes mellitus.

Candesartan and valsartan are licensed for the treatment of patients with heart failure and impaired left ventricle systolic function, (left ventricular ejection fraction < 40%), as add-on therapy to ACE inhibitors or when ACE inhibitors are not tolerated. Losartan may be used as an alternative to an ACE inhibitor.

Cautions: in renal artery stenosis. Monitoring of potassium levels is advised in the elderly and renal impairment; hyperkalaemia may occur.

Sacubitril/valsartan (Entresto®) is licensed for adult patients with symptomatic chronic heart failure with reduced ejection fraction. It should be initiated by specialists only.

On this website you will now see four icons for these resources rather than two. Please use BNF Legacy or BNF for Children Legacy as these will take you to the original format of the online publications which do not have any errors or omissions.